Healthcare Provider Details

I. General information

NPI: 1811038755
Provider Name (Legal Business Name): DAVID MARK VITELLO AGPCNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

PO BOX 22075
MILWAUKIE OR
97269-2075
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-7246
  • Fax:
Mailing address:
  • Phone: 503-353-1272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC175336
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201507396NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: